CONFERENCE REGISTRATION FORM Title: Prof. Dr. Mr. Ms Category: IHPBA Member Yes No IHPBA Membership No. Non-Member Accompanying person PG Student* Foreign Delegate *Certificate from Head of Department is mandatory for PG Student *Name (to appear on certificate & badge) Age Sex MCI State MCI No Designation Institute Address City State Country Pin Code *Mobile Tel. (0) *Email Name of Accompanying Person (s) (1) Name Relation Age/Sex/ (2) Name Relation Age/Sex/ Personal Details (Please fill in BLOCK CAPITAL LETTERS) Field *Marks Are Mandatory Registration Details th 17 Annual Conference of India Chapter of International Hepato Pancreato Billiary Association Registration Fee Includes: 1. Admission to Scientific Sessions & Exhibition, Refreshment during breaks, Lunches & Dinners, Registration Material & Kit, Participation Certificate. 2. For Accompanying Person - Refreshment during breaks, Lunches & Dinners, Registration Material 3. Conference kit is subject to availability for spot registration. 4. We will accept only cash or credit/Debit card for spot registration Registration Cancellation & Refund Policy: 1.Cancellation on or before 30.11.19, 25% registration charges will be deducted. 2.Cancellation after 1.12.19 till 31.12.19, 50% of registration charges will be deducted. 3.No Cancellation or refund after 31.12.19. 4.Registration cancellation will be accepted only against the written request sent by email to [email protected] st before 31 December 2019. The refund process will begin 15 days after the conference (Note: Application bank charges will not be refunded for online registration) CATEGORY th Till 30 November 2019 st th 1 December 2019 to 15 January 2020 Late & Spot IHPBA Member INR 10000 INR 11000 INR 12000 Non Member INR 11500 INR 12500 INR 13500 P.G. Student* INR 5500 INR 6000 INR 7000 Accompanying Person INR 6000 INR 6500 INR 7000 Foreign Delegates USD 150 USD 175 USD 275 INDIA 2020 IHPBA 17 17 17 TH BHUBANESWAR ANNUAL CONFERENCE OF INDIA CHAPTER OF INTERNATIONAL HEPATO PANCREATO BILLIARY ASSOCIATION Conference Secretariat Dr Mohammad Ibrarullah | Organizing Secretary Mobile: 9937377331 Email: [email protected] Web: www.ihpbaindia2020.com Professional Conference Organizer 56, Institutional Area, Sector - 44, Gurgaon-122002, Haryana, India Mr. Rohit Kamra Mob: +91 9818965679 Email: [email protected] INDIA 2020 IHPBA 17 17 17 TH BHUBANESWAR ANNUAL CONFERENCE OF INDIA CHAPTER OF INTERNATIONAL HEPATO PANCREATO BILLIARY ASSOCIATION th th 24 - 26 January 2020 | Hotel Swosti Premium, Jayadev Vihar, Bhubaneswar *All prices are inclusive of GST 18% By demand draft/Multi city cheque/Bank Transfer (applicable only for Indian Delegate) in favor of "International Hepato Pancreato Biliary Association Bhubaneswar” Payable at Bhubaneswar. Account Name - International Hepato Pancreato Biliary Association Bhubaneswar IFS Code - UTIB0000438 Account number – 918020067601334 MICR code – 751211004 Branch Code- 000438 Cheque / DD / NEFT / Transaction No Name of Bank Account Holder Name Total Amount Transaction Date Signature Discount on Early bird Registration. Can be upgraded to residential package on request by adding the room rent. Payment Details Theme: HPB Surgery: Then and Now